Posted by: medicblog999 | January 4, 2010

Decisions, Decisions….What would you do?

choices

Here’s an interesting Dilemma for you to ponder over.

I was working on the Rapid Response car, and had been dispatched to a local private care nursery for a 17 month old girl who had reportedly had a fit, and felt very hot. The initial information on the computer screen told me that she had now stopped fitting and was not a known epileptic.

I arrived on scene within a few minutes and found the girl to be conscious, alert, good colour, moving all four limbs and making eye contact.

The staff on scene had contacted the mother who had arrived just before me (she worked just around the corner; it’s not another NHS horror story about our alleged response times!). She was visibly upset and obviously very concerned. The staff member looking after the child gave a really good description of a grand mal seizure event lasting less than 1 minute. She stated that before going into the fit, she noticed that the child felt very hot to touch and once the fit started, she removed most of her clothing and cooled her down.

As I assessed her, she didn’t feel hot to touch any more, but unfortunately the thermometers we use were not working either so I had to go by touch. General examination showed nothing remarkable. No rashes, no obvious signs of infection, no evidence of any significant signs to worry me. Mum stated that her daughter had a similar episode nearly a year ago which was again put down to a febrile convulsion and no further investigations were done.

As I look at the child and see a relatively happy looking toddler in front of me, I have a number of options open to me.

The first set of options I dismiss straight away; those are the ones where the child doesn’t go to hospital. This could be either referring onto her own GP for an appointment today, or leaving the child with mum to keep an eye on and give them some self care information and advice to call back if any further problems or concerns. In this case, there is no way that I would leave a child without medical assessment following a seizure without a known pre existing diagnosis of epilepsy.

This then leaves the options of:

  • Mum transports child up to the hospital in her own care with a referral report form from me
  • I take Mum and child up to hospital in the Rapid Response car, thereby continuing my ‘episode of care’ until handover at the hospital
  • Call for an ambulance and let them transport the child and mother to the hospital, after a handover from me.

Remember that this child appears to be fully recovered and showing no significant effects of whatever event has just happened.

What would you do? How would you manage this patient and facilitate her follow up care?

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Responses

  1. An ambulance might be a waste of resources (for a straight up asymptomatic transport), if the fits were so far apart as the mother indicated. (year prior)Letting her take her in might be considered neglectful of the possibility of another fit.I say take her in your RRV, that way you can keep an eye on her for a longer period of time to confirm the fits ended (and have all the equipment you need should the fits begin again), and you can confirm the lack of febrility/etc… with equipment at the recieving hospital when you arrive. … then again, I have nearly no experience, so I may be completely off base.-S

  2. I have 2 answers for you, so HA!Answer one is my SFFD answer: Transport. I'm not entirely comfortable leaving mom to drive the kiddo in case something happens, as unlikely as we all know it is, if the kid fits and mom swerves to help and causes an accident, well darn it.Answer 2 is my NEAS answer. RRC them to the appropriate facility or RRC the kid home, following mom just to make sure.Ka and Chow!

  3. Definitely… she needs to be seen…sending her with mom is a risk to them both for various reasons. Take your response vehicle. You're all ready committed there and an ambulance would be a waste of the local resources.

  4. If her vitals are good and she is stable, mom would take her on her own. Have mom write a release and off you go. Thats what we do in America.

  5. As much as I want to be origional and come up with something absolutly brilliant to address this situation; I'm resigned to just go with HM on this one.I would, and have gone as far to follow a patient to within a mile or two of the hospital as a just in case. This is of course provided we are not stacked and the patient just doesn't want to ride the bus to keep from incurring a bill. If anything were to happen, they could just pull over and we take over. Of course if the patient is that serious, I'm not inclined to let them drive. Not with me knowing about it anyway. If they're that bad off, they should cut the losses and go with me.

  6. I'm gonna go with ambulance transport on this one, Mark. My reasoning for this is the crew can monitor the patient and be able to respond to any status changes with a provider in the back and a provider driving. To me, it would seem difficult for a lone provider transporting the patient if something changes and an ambulance might be needed anyway if that occurs.

  7. I would have to say transport by ambulance. The reason being is that even though this child's last seizure was a year prior. The child still had one that day. Thus increasing the chances of another seizure. In the ambulance the are more able to care for the child that just you in your rrv. Just remember even though the child may seem fine it doesnt always mean they are fine until evaluated by a doctor.

  8. Call an ambulance. If she began seizing again on the way to the hosp. you would not be able to properly care for her. Not only that..Which is of course, our 1st concern…can you say potential lawsuit

  9. My choice would be to transport. We would be ASSUMING that the seizure was febrile….not always a good thing to do in my mind. I was always tought to thiknk worst case scenario…standing in coroners court trying to justify why you thought the seizure was not significant enough to warrant more detailed assessment.

  10. I would have to agree with the majority on this. I would transport by ambulance, it's not a waste of resources. If the child was to have another seizure while you are driving things can go bad fast, and it may take to long to pull over. I do agree that we often times get complacent and tend to dismiss things quickly, which is how we end up in court!!

  11. How far are we from the closest appropriate facility?

  12. Release to mom. It more than likely is febrile, and even if it isn't…it's a seizure, not a MI.

  13. Depends how long you would be waiting for a vehicle, and how far from hospital. *Chances are* that it was another febrile convulsion, but it does need to be checked over. Mum taking her in is the best bet for keeping resources available, and is perfect if say the hospital is just around the corner. On the other hand, if you were hours away, I'd send the two in on an ambulance, so there's medical care for the kid if things do kick off. In the intervening scenarios, use the car 🙂

  14. On a normal drive (no lights or sirens), you are looking at about a 20 minute drive to the hospital and possibly at least that for an ambulance to back me up (as I would be putting it in as a Cat C response, no lights and sirens for the ambulance either)

  15. On a normal drive (no lights or sirens), you are looking at about a 20 minute drive to the hospital and possibly at least that for an ambulance to back me up (as I would be putting it in as a Cat C response, no lights and sirens for the ambulance either)

  16. Really this comes down to your own clincal judgement. However, I would say here that (as it is an option to you) that you point the mother in the direction of the GP with appropriate advice of what to do if another episode happens prior to being able to see the GP. I say this because you mention the child's seizure lasted <1 minute, that the child no longer seemed hot to touch (which is all you could go on given your lack of a functioning themomiter). You don't seem to mention anuthing that suggests a serious illness such as meningitis. The probablility that this has been an episode of febril convulsions is high and as such the probability of the child having a further episode in the next 24 hours is low. Had there been anything which would suggests A+E treatment being necessary then I would have had to say transportation by ambulance would have been the most appropriate option.

  17. Personally I would use the RRV to take her into local A&E for two reasons,1) so as not to tie up an Ambulance (granted the RRV is tied up but I would suspect not for as long as waiting for the Ambulance would tie it up)2) Kids that age are sometimes scared of new faces, she is used to your face so adding more might frighten her again etc.(Note im not a Para or a Tech yet!)

  18. I'm not a paramedic or EMT but to me the most sensible option seems to be option 2, transport in RRV.1) It makes sure that the child definitely gets to hospital (even if parent then discharges from there) as you can't guarantee that even with a referral note that mum will take the child.2) It doesn't take up an ambulance for a non-urgent call and also you don't have to wait longer for the transport especially as, although possible, it appears unlikely that the child will have another fit.3) If the worst case scenario does happen and the child has another fit, you are available to treat and call for backup, by which point you'll be closer to the hospital anyway. If you weren't there, the mother would be driving and may panic. As it is, you're driving and the person most likely to spot a change in the child's behaviour (mum) is keeping an eye on her.

  19. My service doesn't have a rapid response car (that is allowed to do transport). We'd either take the child by ambulance or let the mom take the child. We have also let people transport themselves and followed them to the hospital. Before I could answer this I'd also want to know how far they are from the hospital and if the last time this happened did it reoccur or was it just one seizure? I'd probably let mom transport.

  20. Not going to comment on the main question – want to ask another question! What are your thermometers that weren't working? Those things to stick in the ears? If so – how much do you believe of what they say anyway? A Medical Physics department (I think your local one in the NE&Cumbria) has done a study showing they are unreliable (to put it politely). Of course, “England” does seem to have a problem taking advice from the people who really know the science so it's probably irrelevant!

  21. Definitely not a call for an ambulance (but see below). I'd require a bit more info to decide, but here's my reasoning:If mum has a car, it would seem reasonable for you to let mum take the nipper. They will probably need to get back from the hospital, and if the little kid has some kind of infection, she may be feeling dog rough. High temperature suggests possible febrile convulsion and the temperature of young children can go up and down like a yo-yo. To be on the safe side, you could follow and give instructions to stop if the child became distressed or fitted again.With no car, it would be difficult for mum to transport the patient to the hospital – a bus doesn't cut it. If the hospital is close-ish (i.e. within the town), you could take mum & child in the back of the FRV. Technically, of course, this would be illegal – no car seat – but would probably be the right thing to do.If mum didn't have a car AND the hospital was some distance away, forget my first comment. You'd need an ambulance. Taking the pair of them in the FRV for five minutes is a low level of risk, but 20 minutes increases that risk and I wouldn't want to transport a 17 month old on mum's lap for that length of time.Sorry to hedge, but like I said, I'd like more info which you would have. I've posted this “blind” without viewing the other responses, so you may already have been asked for and given extra information.

  22. I wouldn't take the kid via the RRC. If they kid has another seizure are you going to be able to pull over and help while waiting for an ambulance to show up? If there is a transport then I would say go via ambulance. Otherwise, if vitals are stable, there is no obvious “trouble” with the story (i.e. no evidence of trauma, environmental toxicity or disease) I would be comfortable letting the mother transport provided the parents understands the full extent of the potential risks involved. Having said that, I wouldn't be too upset if the mother wanted my truck to take the child. I guess a lot of that would depend on the parents circumstances (e.g a language barrier, inability to understand the situation and/or formulate a course of action).

  23. Not sure on what the rules out in UK are but here in Texas, USA, any rapid response vehicle must be permitted as an ambulance before any “patient” transports would be allowed. Either way in this case I would have to ask what your capabilities are as a rapid response vehicle. Also when was her last seizure (prior to this one)? Has she been sick lately? What was she doing right before her seizure? Vital Signs ok? Did she really have a febrile seizure? Is she compliant on her meds? When she does seize is it usually only a 1 time thing or does she have multiple seizures in a certain time period? Was there a postictal period? Even though she has epilepsy was this a true epileptic seizure or just a febrile (fever induced) seizure. Many questions that require answering but in my opinion from your blog I would go ahead and call an ambulance to make sure that proper care is given at an appropriate time and safety of the patient is garaunteed.TexasMedic

  24. Had I been in your position I would have consulted with the child's mother and strongly advised that she and the child be transported via ambulance to the nearest emergency facility, informing her that should something happen enroute to the emergency department, her child would be given care. I would also advise the mother that because there is no preexisting diagnosis of epilepsy and the child does not feel warm/hot to the touch, that neither can be ruled out as cause for the “fit” without further assessment/treatment. With pediatric patients, I have always chosen to ere on the side of caution. I would much rather be safe than sorry and nearly 100% of the parents I have come into contact with have agreed.

  25. probably take her and mum in car to hospital.

  26. Just curious … what is there to be gained by people transporting themselves and following them in an ambulance? If you've decided they need to go to hospital either they're fit to take themselves there or they're not.

  27. It's a piece of mind thing for the mother. Our bay is about 100 yards from the hospital so it's not that big of a deal to us. Because we're such a small town it's the little things like that that we get remembered for. We barely break 1,000 calls per year (and that includes inter-facility transfers).

  28. It's a piece of mind thing for the mother. Our bay is about 100 yards from the hospital so it's not that big of a deal to us. Because we're such a small town it's the little things like that that we get remembered for. We barely break 1,000 calls per year (and that includes inter-facility transfers).

  29. It's a piece of mind thing for the mother. Our bay is about 100 yards from the hospital so it's not that big of a deal to us. Because we're such a small town it's the little things like that that we get remembered for. We barely break 1,000 calls per year (and that includes inter-facility transfers).

  30. probably take her and mum in car to hospital.

  31. Just curious … what is there to be gained by people transporting themselves and following them in an ambulance? If you've decided they need to go to hospital either they're fit to take themselves there or they're not.

  32. It's a piece of mind thing for the mother. Our bay is about 100 yards from the hospital so it's not that big of a deal to us. Because we're such a small town it's the little things like that that we get remembered for. We barely break 1,000 calls per year (and that includes inter-facility transfers).


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